Gao et al.

BMC Public Health 2013, 13:238

http://www.biomedcentral.com/1471-2458/13/238

RESEARCH ARTICLE Open Access

Oral rehydration salt use and its correlates

in low-level care of diarrhea among children
under 36 months old in rural Western China
Wenlong Gao1, Hong Yan1*, Duolao Wang2 and Shaonong Dang1

Abstract
Background: Since 2000, there has been a decline in the proportion of oral rehydration salts (ORS) therapy in
childhood diarrhea. How to sustain and achieve a high level of ORS therapy continues to be a challenge.
Methods: The data of 14112 households and 894 villages in 45 counties across 10 provinces of Western China
were collected in 2005. Generalized estimated equation logistic regression models were used to identify the
determinants of ORS use in home-based and village-level care.
Results: The therapy rate of ORS was 34.62%. This rate in home-based care (HBC) was significantly lower than that
in village-level care (VLC), township-level care or county-level-or-above care. The children in the families with several
pre-school-aged children (OR = 0.29 95% CI: 0.10, 0.86) or of the smaller age (12 vs 36 months: OR = 0.10 95% CI
0.02, 0.41; 24 vs 36 months: OR = 0.26 95% CI 0.09, 0.77) were less likely to receive ORS therapy against diarrhea in
HBC. The children whose family had the habit of drinking boiled water (OR = 2.77 95% CI 1.30-5.91), or whose
caretakers received educational materials about childhood diseases (OR = 3.08 95% CI 1.54, 6.16), or who were
living in the villages in which village clinics had the available ORS packages (OR = 3.94 95% CI 2.25, 6.90) were
more likely to receive ORS therapy against diarrhea in VLC.
Conclusion: There thus, ORS promoting program should give the highest priority to home care. ORS promoting
strategies for low-level care could be strengthened based on children characteristics, the habit of drinking water
and the situation of receiving educational material in the families and on the availability of ORS packages in village
clinics in rural Western China.

Background anti-diarrhea drugs and antibiotics, which have no clinical

Diarrhea remains a leading cause of death among infants benefits, cannot be allowed in the treatment of acute
and young children [1-4]. The major pathogenic mechan- watery diarrhea [8]. However, even up to 80% of the chil-
ism of diarrhea mortality is dehydration, which is respon- dren with diarrhea in some areas were reported to have re-
sible for more than half of diarrheal deaths in developing ceived no ORS but only anti-diarrheal drugs [8].
countries [5]. Oral rehydration salts (ORS) dissolved in Successful reduction of diarrhea mortality in the 1970s
water to form oral rehydration solution can be absorbed and 1980s can be attributed largely to the scaling-up use
in small intestine, replacing water and electrolytes lost in of oral rehydration therapy and programs to educate
faeces, and is likely to produce fast recovery and fewer side caregivers on its appropriate use. Regional data shows
effects [6,7]. So it is a safe and effective treatment adminis- that since 2000 there has been slight decline in the pro-
tered at home or at medical centers [7]. ORS can prevent portion of children receiving ORS therapy during epi-
93% of childhood diarrhea mortality [4], and the use of sodes of diarrhea [9,10]. So, the simple and effective tool
of child survival has fallen off the priority lists for global
* Correspondence: [email protected] and national policy leaders and program managers [9].
1
Department of Epidemiology and Health Statistics, School of Public Health, How to sustain and achieve a high level of oral rehydra-
College of Medicine, Xi’an Jiaotong University, PO Box 46, Xi’an, Shaanxi tion therapy continues to be a challenge [10].
710061, PR China
Full list of author information is available at the end of the article

© 2013 Gao et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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Households and village clinics play an important role weeks (Diarrhea was defined as the passage of 3 or more
in the management of childhood diarrhea [1,4]. A previ- loose or watery stools in the proceding 24 hours), we fur-
ous report from Mongolia has showed that more than ther interviewed them about the recent diarrheal episode
one-fifth of infant and child deaths occurred at home in detail, including recognition of 7 dangerous symptoms
[11]. In rural China, village clinics located at the first tier of diarrhea (frequent watery stools in the proceeding one
of the rural healthcare system supply the population liv- or two hours, blood in stools, repeated vomiting, high
ing in the village with many services of disease control fever, extreme thirst, no desire to drink and refusal to eat),
and prevention [12]. But village doctors, who were both their care-seeking behaviors and ORS use in different care
peasants and healthcare workers, were inclined to use locations. Meanwhile, we also asked them whether they
medicine inappropriately [12,13]. So, it is of critical im- had received educational materials including the basic pre-
portance for childhood diarrhea to find new strategies of vention or care knowledge of common childhood diseases
promoting and sustaining a high level of ORS use in which were specific in the rural primary health care pro-
home or village-level care against the diarrhea mortality. gram. Then, we collected the data of village clinics from
This study has assessed the utilization rate of ORS in village health personnel through a village clinic question-
the care of diarrhea among children under 36 months naire about the basic information of village doctors, their
old and explored the determinants of ORS use in home- medication and retail pharmacy distribution in the village.
based and village-level care. Such a study can provide To make the collected data available, the chief of the inves-
some insights of promoting ORS use in home-based and tigation team must review every sheet of questionnaire and
village-level care and reducing the deaths due to diar- verify its appropriateness carefully before all questionnaires
rhea among children under 36 months old in rural were accepted. The study was approved by the Ethics
Western China. Committee of College of Medicine of Xi’an Jiaotong
University.
Methods
Setting and study population Variables
Supported by Chinese Ministry of Health and UNICEF, The outcome variables of interest included the ORS use
a rural primary health care survey in 45 counties of in home-based care (HBC) and village-level care (VLC).
west China’s 10 provinces-—Xinjiang, Inner Mongolia, If a child had received care at home, or in a village clinic,
Qinghai, Gansu, Ningxia, Sichuan, Chongqing, Guizhou, a township hospital or a county-level-or-above hospital
Jiangxi and Guangxi was conducted from June to August in a last diarrheal episode during the previous two
2005. These 45 counties were pre-determined but the weeks, he/she was identified as receiving HBC, VLC,
much smaller sampling units as townships and villages township-level care (TLC) or county-level-or-above care
were sampled through a multi-stage probability- (CLC) respectively. HBC indicated that the caretakers
proportion-to-size sampling (PPS) method. Five town- gave some special care or treatment, such as increasing
ships out of each county and four villages out of each the frequency of feeding, giving ORS, increasing fluid in-
sampled township were randomly selected. In the take or medical care, and so on. If a sick child was not
household-sampled process, a completely random sam- given the above-mentioned special care at home or some
pling method was adopted to extract sixteen households care at health facilities, he/she was regarded as receiving
from each village. If a village had more than 16 house- no care (NC). In rural China, all caretakers did not have
holds, 16 households were selected randomly; if a village medical background. Village doctors, many of whom did
had fewer than 16 households, all the households were not receive formal medical education, were engaged
determined and the rest were selected out of the neigh- both in healthcare and farming. Therefore, we identified
boring villages. In every sampled household, only one HBC or VLC as a low-level care. If a child with diarrhea
child under 36 months old was selected randomly and had received ORS packets in a recent diarrheal episode
the caretaker of the selected child was interviewed. in the previous two weeks and all ORS packets were ad-
ministered at the corresponding care location, he/she
Data collection was identified as using ORS at the care location. The
All data in the study were collected by means of pre-coded caretakers’ capacity of judging the danger signs of child-
structured family and village clinic interview question- hood diarrhea was assessed through the number of the
naires. First, we had a face-to-face interview with all the dangerous symptoms of diarrhea they could recognize
caretakers involved in the survey about their families, their out of the 7 ones. The Demographic and Health Survey
children and themselves after they had signed the informed (DHS) wealth index generated with the five variables
consent form. All socio-demographic information in the (type of vehicle, water supply, income resource, texture
study was included in the family questionnaire. If their of pot and type of television) was used to assess the so-
children had suffered diarrheal episode in the previous two cioeconomic status of the families [14,15]. According to
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the tertiles of the DHS wealth index, the economic sta- Table 1 Sample characteristics and village-level information
tuses of the families fell into three: poor, medium and by HBC and VLC
rich [14,15]. Information All n (%) HBC n (%) VLC n (%)
Household-level information 1040(100.00) 153(14.71) 413(39.71)
Data analysis Number of family members (<4) 228(21.92) 46(30.07) 84(20.34)
The data from the qualified questionnaires was entered Number of pre-school-aged 456(43.85) 63(41.18) 183(44.31)
in Epidata 3.1 by double entry. SPSS version 17 (SPSS children (>1)

Inc, Chicago, IL, USA) was employed to make the statis- Drinking boiled water usually 839(80.67) 119(77.78) 343(83.05)
tical analysis. The chi-square test was adopted to com- Economic status of the family
pare the proportions. Generalized estimated equation Rich 275(26.44) 36(23.53) 134(32.45)
(GEE) logistic regression models were used to predict Medium 209(20.10) 31(20.26) 79(19.13)
the determinants of ORS use in HBC and VLC respect- Poor 556(53.46) 86(56.21) 200(48.43)
ively while controlling for the possible correlation of Mother care 873(83.94) 136(88.89) 325(78.69)
ORS use in the same village. The level of the significance Han ethnicity 551(52.98) 49(32.03) 250(60.53)
of analysis was set at 0.05.
Age of mothers (25–34 year) 562(54.04) 74(48.37) 249(60.29)
Maternal education (0–9 years) 964(92.69) 145(94.77) 400(96.85)
Results
Receiving educational materials 823(79.13) 117(76.47) 330(79.90)
Sample characteristics and village-level information about childhood diseases
The study investigated 14112 households and 894 vil- The number of danger signs 2.92,1.85 2.46(1.26) 3.08(1.96)
lages totally. In these surveyed households, 1040 chil- recognized (mean, SD)
dren had suffered at least one of diarrheal episodes in Age of diarrhea children
the previous two weeks. Table 1 shows sample character- 0-12 months 509(48.94) 59(38.56) 191(46.25)
istics and village-level information by HBC and VLC. 13-24 months 360(34.62) 56(36.60) 147(35.59)
Extra analysis of care-seeking behavior (results not 25-36 months 171(16.44) 38(24.84) 75(18.16)
displayed) showed that of the children with diarrhea,
Boy 615(59.13) 86(56.21) 247(59.81)
about 9% received NC, slightly less than 15% received
Breastfeeding when surveyed 534(51.26) 75(49.02) 197(47.70)
HBC, approximate 40% sought VLC, 27.3% were sent to
Oral vitamin A in the previous year 583(56.06) 89(58.17) 243(58.84)
township hospitals for diarrhea and 9.52% sought the
b
Village-level information (n)
care in county-level or above medical sectors.
Additionally, all children with diarrhea were living in Number of retail pharmacies (≥1) 63(11.93) 7(6.49) 45(15.68)

537 villages of 204 townships. Of these villages, most Number of village doctors (one doctor) 321(60.80) 77(71.30) 258(89.90)
had no retail pharmacies and about 60% had only one Age of village doctors (≥35 years) 360(68.18) 72(66.67) 182(66.90)
village doctor. Only two-fifths of village clinics had some Education of village doctors 266(50.38) 43(39.81) 162(56.45)
(Technical school and above)
ORS available (Table 1).
Practice period of village doctors 297(56.25) 65(63.11) 170(59.23)
(≥10 years)
Use of ORS
Available ORS in village clinic 208(39.39) 22(20.37) 134(46.69)
Table 2 shows ORS use for diarrhea among children a
HBC, home-based care, VLC, village-level care.
under 36 months old in 10 provinces of rural Western b
The information of nine villages was missing.
China. The overall utilization rate of ORS was 34.62%
(95% CI: 31.72, 37.51). In the four kinds of care, the use (x2 = 14.31, p = 0.026) when controlling for
utilization rate of ORS in TLC was the highest (45.77%), breastfeeding status. Among 15 pairwise comparisons,
that in HBC the lowest (only 15.03%), and that in VLC four pair was significantly different (6 vs 36 months: p =
and in CLC 41.89% and 34.34% respectively. Figure 1 0.004; 12 vs 36 months: p = 0.009; 24 vs 36 months: p =
shows the utilization rate of ORS in different care. There 0.017; 30 vs 36 months: p = 0.032).
was a significant difference in ORS use among the 4 care
groups (x2 = 32.47, p < 0.001). By six pairwise compari- Determinants of ORS use in low-level care
sons, the utilization rate of ORS in HBC was signifi- Table 3 shows the predictors of ORS use in HBC and
cantly lower than that in VLC, TLC or CLC. (HBC vs VLC among children with diarrhea under 36 months
VLC: p < 0.001; HBC vs TLC: p < 0.001; HBC vs CLC: p old. GEE model analysis of ORS use in HBC demon-
< 0.001). Figure 2 shows the utilization rate of ORS in strated that the caretakers with more than one child
HBC, VLC and average level at all care in the 6 age- seemed less likely to use ORS in recent diarrheal episode
groups (0-6 months, 7-12 months, 13-18 months, 19- and that the younger children were less likely to use
24 months, 25-30 months and 31-36 months). In the 6 ORS in HBC. GEE model analysis of ORS use in VLC
age-groups, we observed a significant difference in ORS demonstrated that the families’ habit of drinking boiled
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Table 2 ORS use for diarrhea among children under when to appropriately use ORS. The previous study also
36 months old in 10 provinces of rural Western China showed that the devalued status of ORS in the eyes of
Number of The number of ORS use caretakers had become a major problem [17]. It should
households children with
Province
surveyed (n) diarrhea in previous
n % be acknowledged that these children with diarrhea in
two weeks (%) HBC usually had symptoms not as severe as those who
Gansu 634 27 (4.26) 6 22.22 were taken to a formal healthcare facility. These may
Guangxi 1586 58 (3.66) 19 32.76 lead to the low utilization of ORS in HBC. So programs
Guizhou 1265 116 (9.17) 43 37.93
of promoting ORS use should give a significant priority
to the households. Meanwhile, communication strategies
Jiangxi 1567 74 (4.72) 42 56.76
are needed to ensure that families understand and
Inner Mongolia 1217 65 (5.34) 5 7.69
accept ORS as a key treatment component in HBC [1].
Ningxia 1264 79 (6.25) 29 37.18 Also, there should be an urgent need for caregivers to be
Qinghai 1589 119 (7.49) 32 26.67 educated to use ORS packets at home as early as pos-
Sichuan 1577 158 (10.02) 94 59.49 sible when a diarrheal symptom appeared in their chil-
Xinjiang 2168 315 (14.53) 75 23.81 dren. GEE model analysis of ORS use in HBC found that
Chongqing 1245 29 (2.33) 14 48.28 the caretakers who cared for more than one child
All 14112 1040 (7.37) 360 34.62
seemed less likely to use ORS in recent diarrheal epi-
sode. In the multi-child families in rural China, it is
ORS = oral rehydration salts.
common for the caretakers to delegate some care bur-
dens to their older children. However, other children in
water, caretakers’ receiving educational materials about the household may not have the appropriate knowledge
childhood diseases and ORS available in village clinics or skills to care for a younger sibling with diarrhea. The
seemed to increase the likelihood of ORS use. demands of caring for multiple children negatively im-
pacted caretakers’ ability to provide appropriate and
Discussion timely diarrheal treatment for the ill child. This may
Oral rehydration therapy is the cornerstone of fluid re- contribute to low use of ORS packets for sick child in
placement and national programs to promote ORS have families with multiple children. Our study also found
been strongly supported by WHO, UNICEF and USAID that the younger children were less likely to use ORS in
in the treatment of diarrhea [1,16]. Our study found that HBC. Due to the fact that younger children were more
the overall therapy rate of ORS in all care of diarrhea likely to be breastfed or fed with more liquid food, care-
among children under 36 months old is 34.62%. In the 4 takers would not like to think it necessary to use ORS
care groups, the utilization proportion of ORS in HBC frequently in their children with diarrhea in such a feed-
was only 15.03%, significantly lower than that in VLC, ing period [18]. In addition, a similar study of ORS ther-
TLC or CLC. It was clear that these caretakers did not apy in rural Bangladesh demonstrated that the mothers
use ORS against childhood diarrhea in HBC more often. generally had the perception that infants should not
In our study, overwhelming majority of the mothers of drink any fluids other than breast milk before this age,
these children completed only a primary education. It is and the infants were introduced to water and other clear
possible that this may contribute to less education about fluids after this age [19]. In rural China, such a

Figure 1 ORS use in the sought care of diarrhea among children under 36 months old in rural Western China.
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Figure 2 ORS use for diarrhea in the 6 age-groups by home-base care, village-level care and average level of all care among children
under 36 months old in rural Western China.

perception among the caretakers in home care may also

be a factor, explaining why children less than 12 months
old were offered ORS less frequently in HBC than those
Table 3 Predictors of ORS use of diarrhea children below aged 25–36 months. So health communications should
36 months old in the low-level care in rural Western China specifically inform caregivers that ORS can be used in
d
Univariate Multivariate sick children who are currently being breastfed.
Variables
OR 95% CI OR 95% CI The utilization rate of ORS in VLC (41.89%) was only
a,c
ORS use in HBC lower than that in TLC (45.77%). Recent study of pre-
Number of pre-school-age children scriptions of village doctors in these areas has shown
>1 0.46 0.19,1.10 0.29 0.10,0.86
that in the village clinics more than one-third of the
doctors had no full-time medical education and village
1 1 1
doctors were inclined to adopt inappropriate drug utili-
Age of children zations in the treatment of diarrhea [12,13]. More edu-
0-12 months 0.17 0.05,0.59 0.10 0.02,0.41 cational or training projects about appropriate and early
13-24 months 0.43 0.16,1.15 0.26 0.09,0.77 ORS use by the government should be carried out in
25-36 months 1 1 village-level medical sectors urgently. GEE model ana-
b
ORS use in VLC
lysis of ORS use in VLC showed that ORS use was posi-
tively associated with the habit of drinking boiled water
Drinking water
often in the families. Families that drank boiled water
Boiled water often 2.82 1.57,5.05 2.77 1.30,5.91 often at home may have more faith in ORS as a treat-
No or boiled water occasionally 1 1 ment or consider it standard treatment of childhood
Receiving educational materials diarrhea. When they took their children to village
about childhood diseases clinics, they also agreed that village doctors could use
Receiving 3.52 2.03,6.11 3.08 1.54,6.16 ORS for their children with diarrhea. Our study also
Non-receiving 1 1 showed that receiving educational materials about child-
Available ORS in village clinics hood diseases was more likely to increase the likelihood
of ORS use in VLC. The prescription of ORS in village
Yes 3.96 2.54,6.19 3.94 2.25,6.90
clinics seemed to meet with the profile of educational
No 1 1
materials about the treatment of childhood diarrhea and
a
Fourteen household-level variables were entered together into GEE thus made the caretakers more likely to believe in the
logistic model.
b
Fourteen household-level variables and six village-level variables were decision of village doctors to use ORS. Our study also
together entered into GEE logistic regression model. cHBC = home-based care; found that ORS available in village clinics was more
VLC = village-level care; ORS = oral rehydration salt; OR=odds ratio;
CI = credible interval.
likely to increase the use of ORS, as found by a study of
d
Only predictors at 5% of multivariate analysis model were listed. ORS use at home [20]. Thus, when ORS packets were
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not available in village clinics, self-made ORS based on Received: 27 October 2012 Accepted: 13 March 2013
the WHO formulation could be used to treat children Published: 19 March 2013

with diarrhea. References

1. UNICEF/WHO: Diarrhea: why children are still dying and what can be done.
Limitation UNICEF; 2009. http://www.who.int/maternal_child_adolescent/documents/
9789241598415/en/index.html.
Some limitations of our study should be acknowledged. 2. Bryce J, Boschi-Pinto C, Shibuya K, Black RE: WHO estimates of the causes
As it had not been designed to collect all the informa- of death in children. Lancet 2005, 365:1147–1152.
tion about ORS use, some important information such 3. Tate JE, Burton AH, Boschi-Pinto C, Steele AD, Duque J, Parashar UD: WHO-
coordinated Global Rotavirus Surveillance Network: 2008 estimate of
as the dose, type and frequency of ORS therapy and so worldwide rotavirus-associated mortality in children younger than
on was not available, which could affect our results. 5 years before the introduction of universal rotavirus vaccination
Moreover, all data were collected by self-report, which programmes: a systematic review and meta-analysis. Lancet Infect Dis
2012, 2:136–141.
might involve some recall biases. Besides, some other 4. Munos MK, Walker CL, Black RE: The effect of oral rehydration solution
confounding factors which might potentially affect the and recommended home fluids on diarrhea mortality. Int J Epidemio
incidence of childhood diarrhea such as the severity of 2010, 39:75–87.
5. Bhandari N, Bhan MK, Sazawel S: Mortality associated with acute watery
childhood diarrhea, might also affect ORS use. In diarrhea dysentery and persistent diarrhea in rural North India. Acta
addition, use of ORS in HBC or care of clinic or hospital Paedriatrica 1992, 381:3–6.
will likely depend on the perceived severity of the diar- 6. Saengcharoen W, Lerkiatbundit S: Practice and attitudes regarding the
management of childhood diarrhea among pharmacies in Thailand.
rhea. But this survey did not collect the information Int J Pharm Pract 2010, 18:323–331.
about severity of childhood diarrhea. This also may 7. WHO: The treatment of diarrhoea: a manual for physicians and other senior
affect our study results potentially. health workers. WHO; 1995. http://www.who.int/maternal_child_adolescent/
documents/9241593180/en/.
8. Muhuri PK, Anker M, Bryce J: Treatment patterns for childhood diarrhea:
Conclusion evidence from demographic and health surveys. Bull World Health Organ
1996, 74:135–146.
In conclusion, the utility rate of ORS in HBC was the 9. Fischer Walker CL, Fontaine O, Young MW, Black RE: Zinc and low
lowest in all sought care. So, ORS promoting program osmolarity oral rehydration salts for diarrhea: a renewed call to action.
should give the highest priority to home care. The num- Bull World Health Organ 2009, 87:760–766.
10. Enzley S, Barros F: A global review of diarrhoeal disease control. UNICEF; 1997.
ber of pre-school-aged children in a family and the chil- http://rehydrate.org/diarrhoea/pdf/diarrhoea-global-review.pdf.
dren’s ages affected ORS use in HBC. The families’ habit 11. Ministry of Health Mongolia: Care practices for young children in Mongolia.
of drinking boiled water, educational materials about UNICEF; 2000. http://www.unicef.org/evaldatabase/index_14119.html.
12. Dong L, Yan H, Wang D: Polypharmacy and its correlates in village health
childhood diseases and the availability of ORS in village clinics across 10 provinces of Western China. J Epidemiol Community
clinics affected ORS use in VLC. ORS promoting strat- Health 2010, 64:549–553.
egies for low-level care could be strengthened based on 13. Dong L, Wang D, Gao J, Yan H: Doctor’s injection prescribing and its
correlates in village health clinics across 10 provinces of Western China.
children characteristics, the habit of drinking water and J Public Health 2011:1–6. doi:10.1093/pubmed/fdr019.
the situation of receiving educational material in the 14. Rutstein SO, Johnson K: The DHS wealth index, DHS comparative reports 6.
families and on the availability of ORS packages in vil- Calverton, Maryland: ORC Macro; 2004:8–10. http://resources.vam.wfp.org/
sites/default/files/DHS_WI_Methodology.pdf.
lage clinics in rural Western China. 15. Gao W, Dang S, Yan H, Wang D: Care-seeking pattern for diarrhea among
children under 36 months old in rural Western China. PLoS One 2012,
Competing interest
7:e43103. doi:10.1371/journal.pone.0043103.
All authors declare no conflict of interest.
16. Ann L, Mitra SN: Usage of oral rehydration solutions(ORS): a critical
assessment of utilization rates. Health Policy Plan 1992, 7:251–259.
Authors’ contributions 17. Howteerakul N, Higginbotham N, Freeman S, Dibley MJ: ORS is never
WG designed the study, conducted the data analysis and prepared the enough: physician rationales for altering standard treatment guidelines
manuscript; HY directed the study and the writing; DW assisted with the when managing childhood diarrhea in Thailand. Soc Sci Med 2003,
data analysis and reviewed the manuscript; SD directed and reviewed the 57:1031–1044.
manuscript. All authors have read and approved the final manuscript. 18. Rao KV, Mishra VK, Retherford RD: Knowledge and use of oral rehydration
therapy for childhood diarrhoea in India: effects of exposure to mass
Acknowledgements media. National Family Health Survey Subject Reports 1998. http://pdf.usaid.
The study was supported technically and financially by the Chinese Ministry gov/pdf_docs/PNACD827.pdf
of Health (MOH) and the United Nations Children’s Fund (UNICEF). Neither of 19. Ali M, Atkinson D, Underwood P: Determinants of use rate of oral
the funding sources had any role in the study design, the collection, analysis, rehydration therapy for management of childhood diarrhea in rural
interpretation of data and the writing of the report, nor did in the decision Bangladesh. J Health Popul Nutr 2000, 18:103–108.
to submit the paper for publication. We would like to thank all the 20. Sodemann M, Jakobsen MS, Molbak K, Martins C, Aaby P: Management of
organizers and implementers for their participation in this study. We are also childhood diarrhea and use of oral rehydration salts in a suburban west
greatly grateful to all the investigators for their contribution to data African community. Am J Trop Med Hyg 1999, 60:167–171.
collection.
doi:10.1186/1471-2458-13-238
Author details
1 Cite this article as: Gao et al.: Oral rehydration salt use and its correlates
Department of Epidemiology and Health Statistics, School of Public Health, in low-level care of diarrhea among children under 36 months old in
College of Medicine, Xi’an Jiaotong University, PO Box 46, Xi’an, Shaanxi rural Western China. BMC Public Health 2013 13:238.
710061, PR China. 2Department of Medical Statistics, London School of
Hygiene and Tropical Medicine, London WC1E 7HT, UK.